Neuromonitoring During Robotic Cochlear Implantation: Initial Clinical Experience
- 127 Downloads
During robotic cochlear implantation a drill trajectory often passes at submillimeter distances from the facial nerve due to close lying critical anatomy of the temporal bone. Additional intraoperative safety mechanisms are thus required to ensure preservation of this vital structure in case of unexpected navigation system error. Electromyography based nerve monitoring is widely used to aid surgeons in localizing vital nerve structures at risk of injury during surgery. However, state of the art neuromonitoring systems, are unable to discriminate facial nerve proximity within submillimeter ranges. Previous work demonstrated the feasibility of utilizing combinations of monopolar and bipolar stimulation threshold measurements to discretize facial nerve proximity with greater sensitivity and specificity, enabling discrimination between safe (> 0.4 mm) and unsafe (< 0.1 mm) trajectories during robotic cochlear implantation (in vivo animal model). Herein, initial clinical validation of the determined stimulation protocol and nerve proximity analysis integrated into an image guided system for safety measurement is presented. Stimulation thresholds and corresponding nerve proximity values previously determined from an animal model have been validated in a first-in-man clinical trial of robotic cochlear implantation. Measurements performed automatically at preoperatively defined distances from the facial nerve were used to determine safety of the drill trajectory intraoperatively. The presented system and automated analysis correctly determined sufficient safety distance margins (> 0.4 mm) to the facial nerve in all cases.
KeywordsImage-guided Electromyography Facial nerve Stimulation Multipolar Bipolar Safety Submillimeter Accuracy
The authors thank Laetitia Racz-Perroud, Fabian Zobrist and Marco Matulic (CAScination AG) for technical support. The authors thank Dr. Thilo Krüger and Celine Wegner (inomed GmbH) for technical support. Dr. Thomas Wyss-Balmer contributed with electrical modeling of the presented stimulation probe. Surgical photographs are attributed to Gianni Pauciello.
Conflict of interest
This work was supported by the Swiss Commission for technology and innovation (Project MIRACI 17618.1), the Swiss National Science Foundation (Project 205321_176007), by MED-EL GmbH (Innsbruck, Austria) and CAScination AG (Bern, Switzerland).
- 1.Anso, J., K. Gerber, S. Weber, K. Thorwarth, A. Chacko, and J. Patscheider. Intervention Device with Electrodes, P5324EP00, 2018.Google Scholar
- 2.Anso, J., et al. Electrical impedance to assess facial nerve proximity during robotic cochlear implantation. IEEE Trans. Biomed. Eng. 1–1, 2018.Google Scholar
- 20.Rathgeb, C., et al. The accuracy of image based safety analysis for robotic cochlear implantation. Int. J. Comput. Assist. Radiol. Surg. Google Scholar
- 21.Roland, A. P. S., C. Editor, and A. D. Meyers. Principles of Electrophysiologic Monitoring, pp. 1–9, 2012.Google Scholar
- 23.Silverstein, H., and S. Rosenberg. Intraoperative facial nerve monitoring. Otolaryngol. Clin. N. Am. 24(3):709–725, 1991.Google Scholar